1986, 05-01 Permit App: 00010813 Residence(THIS IS NOT A PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
•
Project Number
Owner's Name LAST FIRST MI
6,GlrG. go 1.v -i -
Project Address (Street Name & Number) Zip
5.14- '3 140 2,
Applicant
O''CJjN,G t (.... ter. is,,,.i f
Address
12 ) z S- a Lc 4--k
City
State
Zip
Phone
Business Phone
Contractor/ Agent((
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Add ess
rit.CL.
/ 1,(-/L) (C frit—
City
ity
crG{�,,
State
Wes
Zip
4 Z16
Phone
( ) 26-0 6G?,
Contact(, /�
___/"1", 'r", of of KI
t1_,
License Number (Required)
L..ENJAc . iS. 17 S
Business Phone
( ) Q,Z,‘ — oc c ?e
Architect/Engineer
Address
City
State I Zip
I
Phone
( )
Contact
Business Phone
( )
Lender
Add ess
City
State
Zip
Phone
1
Describe Work : '
Res.
Comm.
Subdivision/Plat Name/Short Plat Number
t.(S jcvN `S t! 47 %- c. o r E.4?trtA---C
Assessor Parcel Number
`
3�±— o�1.07
Lot %
1
Block
1
Plat Number
Pertinent File Numbers
Zone
'SF
Comp. Plan
Census Tract
Number of Dwelling Units
t
Number of Buildings
l
Lot Size (Sq. Ft./Acre)
Depth
Frontage
17 t. t -t-
Front Setbackj �i
3i I
Left Setback t
15"
Right Setback
2.2 t 4'
Rear Setback
Z12)1
R/ W Width r
,b r t: 5„6
Additional Information
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I BUILDING INFORMATION
Square Footage
PAF (11C
i 1 6,
.ate p
=L;- !..
Number of Bedrooms
•°•x Date
Group
Type
4
DEPARTMENTAL REVIEW
I certify that I have examined this application and state that the Information contained in it and submitted
by me or my agent to compile said application is true and correct.
Signature Date
Approved
Cond.
Approval
Hold
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Q/ r1
Environmental Health ' Application */ V 1 - 0.0q, I !2
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t t
7
c',
3-
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W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers �/ Q
N. 811 Jefferson 40/�'yJ iC-710
4414
I,
Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that I have examined this application and state that the Information contained in it and submitted
by me or my agent to compile said application is true and correct.
Signature Date
r
1